Enter & View Report Discharge Process Hull & East Yorkshire Hospitals Hull Royal Infirmary Anlaby Road Hull Premises visited during March 2015 by Healthwatch Kingston upon Hull Enter & View Ambassadors
Contents: Purpose of visit Introduction Discharge process Patient information Findings Conclusions Recommendations Appendices: Appendix 1: Visit detail Appendix 2: Visit record sheet Appendix 3: Patient discharge leaflet Appendix 4: Ticket home
Purpose of visit Healthwatch Kingston upon Hull have received a number of contacts from patients regarding discharge from Hull Royal Infirmary (HRI). These contacts have related to delays in leaving HRI once patients have been discharged by Consultants. The purpose of this visit is to ascertain reasons for delays in patients leaving the hospital and gather patient opinion of the discharge process. We have previously undertaken two discharge surveys at HRI & CHH to collect patient feedback by post but these have produced limited responses. It was agreed that in order to collect patient feedback at the time of discharge we would undertake two visits to the patient lounge and two sets of visits to wards to speak to patients in the process of discharge. Follow up letters were sent to patients who had consented to be contacted to gain feedback of the complete discharge process. Subsequent to any visit a report is prepared, factual detail agreed by the manager of the facility visited, and then shared with the HWKuH Board before distribution. The visits were pre-arranged. We used prepared questionnaires to find out relevant facts, observed all aspects of the premises or specific areas and spoke to staff, residents and visitors as relevant. Disclaimer: This report relates only to the service viewed on the date of the visit, and is representative of the views of the service users who contributed to the report on that date.
Introduction Hull Royal Infirmary (HRI) is one of two sites operated by Hull & East Yorkshire Hospitals NHS Trust (HEYHT). HEYHT were established in October 1999 following the merger of the Royal Hull Hospitals NHS Trust and East Yorkshire Hospitals NHS Trust. HRI is on one of the main roads leading into the city and is close to bus routes and within walking distance of the train station. HRI currently has approximately 700 beds, however during our visit the site was undergoing a period of redevelopment which included some services being moved from the Castle Hill Site to the HRI site. The HRI site also houses the new Emergency Department, Women & Children s department (including maternity), Renal, Surgery, the eye hospital and a large amount of outpatient facilities. Hull York Medical school and HEYHT administration are also housed on the HRI site. The site is made up of a large tower block with 13 floors, and an additional 3 story building making up the rear wing of the tower block. A number of new buildings have been added to the site over recent years with much of the adjacent land being utilised. There are a number of 3 story Victorian wards towards the rear of the site which are no longer used. The main tower block was opened in 1967 and replaced the old infirmary in the city centre. Many Thanks to Sarah Bates, Assistant Chief Nurse, and members of her team and support staff who provided us with the opportunity to meet patients, and freely ask questions to enable us to understand both the discharge process and patient experience.
Discharge Process The trust has a published discharge process which is communicated to patients by leaflets and posters displayed in wards (appendix 3 & 4). The process described in the patient information includes details around times of discharge, transport, medication and any required support. The process is supported by the use of the Ticket Home system which requires that the patient be issued with a ticket home card upon admission. This card gives similar information to the leaflet described above as well as information regarding a patient stay in hospital and an estimated discharge date (EDD). All patient information relating to discharge gives an expectation that discharge will be in the AM. There is a patient lounge available for patients to wait in comfort for medication or transport if clinically appropriate. The patient lounge is located on the ground floor of the tower block, on the corridor leading to the Emergency Department. The patient lounge is a large bright & airy room with 10 seats and additional space for wheelchairs, there is a patient toilet available and a hearing loop is in use with clearly visible signage. Patients are provided with refreshments and biscuits during their wait with sandwiches being available if a patient is in the lounge during mealtimes. There is no provision for hot food in the patient lounge. Patient Information We spoke at length to a large number of patients and staff during our visits. Of the patients spoken to 12 completed our discharge survey. Approximately half of the patients who completed our surveys were registered with East Riding of Yorkshire GP practices, this information has been shared with the HWERY. 8 of the patients who completed surveys were in the over 65 age bracket which seems to reflect local patient demographics. The response to the surveys was mostly patients who had been inpatients for less than 7 days. Only 1 patient spoken to had been moved between wards during their stay.
Findings From our conversations with patients and completion of questionnaires it was apparent that a large proportion of patients were unaware of why they were waiting to go home. Patients had medication and assumed they were waiting for transport when in most cases they were waiting for either medication or discharge paperwork. Discussion with staff confirmed the discharge process as follows: patients are seen by consultants and advised that they are to be discharged, consultants complete all rounds before completion of discharge paperwork Once discharge paperwork is received medication is ordered from Pharmacy Once medication is received transport is booked Patients can be transferred to the discharge lounge at any point during the process. Transport booking is done by either the ward or the lounge dependant on where the patient is located when all discharge requirements are in place. Staff and patients reported delays in all aspects of the process specifically: Time taken for medication from Pharmacy (patient lounge get priority service) Time taken for discharge paperwork to be produced Time spent on hold when booking transport (15 minutes during our visit) Length of time between transport booking and arrival
All of the patients had nothing but praise for staff and treatment, the only issues raised were time spent waiting either in A&E or to go home. All staff were happy that all belongings had been returned to them. Not all patients spoken to felt that they had been given the opportunity to discuss their discharge and several said that it felt rushed. Patients advised that their discharge dates had been moved several times and in some cases they had not been kept informed of this. None of the patients we spoke to had been given, or were aware of, a ticket home. When we discussed the ticket home with the ward staff we were advised that it wasn t used as the estimated discharge date fluctuates so much that they would be constantly crossing out or re-issuing them. We were provided with a ticket home as an example but this was under a pile of paperwork and not in use. During our visits to wards we were given a list of all proposed discharges for that date, however once on the ward it was apparent that the situation was constantly changing and that the use of Cayder boards was invaluable when managing patient flow and discharge. During our visits usage of the patient lounge varied, we observed discharge lounge staff going to collect patients after identifying them as suitable to wait in the lounge, as well as porters bringing patients down from wards. It was not clear after discussion with staff whether it is the responsibility of the ward or patient lounge to identify patients who are suitable for a discharge lounge wait and transport them to the patient lounge. It was also unclear as to whether all departments worked to the same criteria for patient suitability for movement to the patient lounge or if there were any specific criteria set out in the discharge process. Staff spoken with on wards advised us that the patient lounge is not considered to be suitable for patients with dementia, again it was unclear as to whether this was a criteria put in place by HEYH as part of the discharge process or at the discretion of individual wards.
We observed a number of occasions when transport had been booked by the ward and patients subsequently moved to the discharge lounge. Ambulance staff had not been aware of the movement and had gone to collect patients from the ward, to be told that they were in the discharge lounge. This was causing delays in the patient being collected and also causing some issues in staff and ambulance crew relations. Again the process is unclear but it would seem that that it is the responsibility of whoever booked the transport to advise of the patients location change, it was suggested that the delay in connection to the Patient transport service booking line may add to this miscommunication. We were advised by staff that the patient lounge is not a permanent department and as such does not have a fixed staffing structure or rota. There are always 3 staff in the patient lounge however these are bank staff, 1 of which is permanently allocated to the patient lounge. Opening times of the patient lounge vary dependant on need and staffing, we were advised of one occasion when the patient lounge was open till almost 10pm as a patient waited for transport. We were unable to ascertain whether the patient lounge would be open during our scheduled Saturday AM visit prior to arrival due to no fixed rota being in place.
Conclusions Our observation found that there are a number of factors affecting patient discharge experience at HRI. Timing Each element of discharge has its own timeframe, which causes delays to the patient Communication staff are not effectively communicating with each other regarding patient suitability for and movement to the patient lounge Communication Patients are unaware of the reason for their wait Process - Different departments have different ways of working. This was apparent in the differing answers to our questions and seems to be adding to the general confusion felt by patients around discharge. The overwhelming sentiment of patients we spoke to was that of praise for the staff and the level of care they had received. Patients were very aware of difficulties at the trust and felt that staff were doing a fantastic job under, sometimes, difficult circumstances.
Recommendations Further to our visits we would make the following recommendations: HEYH to conduct a review as to the use of Ticket Home and its inclusion in discharge processes HEYH to ensure that a Trust discharge process, suitable for use by all wards and to include responsibility for PTS transport booking and liaison, is adhered to HEYH to conduct review of patient lounge usage and staffing, and its inclusion in discharge processes HEYH to conduct a review of IDL timescales and reasons for delays
Appendix 1 Visit Details Visits were carried out by the following Healthwatch Kingston upon Hull Enter & View Ambassadors: Graham Gedney Christina Hamilton John Wilkinson Veronica Miller Accompanied by Healthwatch Kingston upon Hull Insight & Intelligence Officer: Gail Purcell. All Enter & View Ambassadors are fully trained in accordance with Healthwatch policy and have undertaken Disclosure & Barring service (DBS) checks. The visits were carried out over the following dates and times: Monday 16 th March Wednesday 18 th March Saturday 21 st March Friday 27 th March 2 4pm 10am 12pm 10am 12pm 2 4pm
Appendix 2 HRI discharge Enter & View record sheet Premises (ward) visited: HRI Anlaby Road Ward Date of visit: 18.3.15 Time of discussion: HW reference: KuH15-03-08(ii) Premises representative: HW Ambassador: Patient Information Name Response / Notes / Observations Address Post-code Contact Number e-mail Preferred method of contact Registered GP Practice Gender Age Range 18-25 26-35 36-45 46-55 56-65 Over 65 Which ward(s) have you been a patient on during your stay Date admitted to HRI
Discharge Information (Ward visits) Has an agreed care plan in place in preparation for your discharge Have other services which need to know been advised of your discharge from Hospital (e.g GP) Have you been given a discharge letter or ticket home? Were you kept informed of your expected discharge date and were any changes clearly explained to you? Were you able to discuss arrangements for leaving hospital with staff and talk about any concerns you had? Has all of your property (including clothing) returned to you ready for when you leave the ward? Are you aware if your family / carers have been provided with information regarding your discharge from Hospital? Yes/No Response / Notes / Observations Discharge Information (Patient Lounge visit) What time did you leave the ward What was the last meal / drink you were provided on the ward? (breakfast / lunch / evening meal) Have you eaten / drunk during your time in the patient lounge? Yes/No Response / Notes / Observations Reason for wait in patient lounge: Awaiting medication Awaiting discharge paperwork Awaiting equipment Have all unnecessary medical devices been removed (e.g. device for a drip) Awaiting transport (Ambulance / private)
Was an agreed care plan in place before you left the ward Have other services which need to know been advised of your discharge from Hospital (e.g GP) Have you been given a discharge letter or ticket home? (please mark in reason for wait) Were you kept informed of your expected discharge date and were any changes clearly explained to you? Were you able to discuss arrangements for leaving hospital with staff and talk about any concerns you had? Was all of your property (including clothing) returned to you when you left the ward? Are you aware if your family / carers have been provided with information regarding your discharge from Hospital? Is there anything else you would like to tell us about your stay in Hospital?
Enter & View Ambassador comments: I give consent for Healthwatch Kingston upon Hull to contact me by phone / e-mail / letter (delete as applicable) to discuss my discharge from Hospital Signed: Date: Signed (EVA): Date / Time: Healthwatch Enter & View Ambassador Information Colour To be completed During all visits When speaking to patients in the discharge lounge When speaking to patients on wards